Lecture notes for medical students

1. Tips on using my ppts.
1. You can freely download, edit, modify and put your
name etc.
2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Etiology ) > Ask students
what they already know about etiology of todays’s topic.
> Then show next slide which enumerates etiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also.
7. See notes for bibiliography.

2. Learning Objectives
1.

3. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.
•

5. Introduction & History.
• Bladder (vesical) calculi are stones or
calcified materials that are present in the
urinary bladder.
• The presence of upper urinary tract calculi
is not necessarily a predisposition to the
formation of bladder stones.

6. Relevant Anatomy
•

7. Relevant Anatomy
• Most vesical calculi formed de novo within
the bladder, but some initially may have
formed within the kidneys.
• Stones composed of calcium oxalate usually
originate in the kidney.

8. Aetiology

9. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoing/ Toxins/ Dtug induced

10. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoing/ Toxins/ Dtug induced

11. Predisposing Factors
•

12. Predisposing Factors
• Bladder outlet obstruction
• Neurogenic bladders
• Indwelling catheters
• Radiation cystitis
• Schistosomiasis
• Congenital or acquired vesical diverticula
• Sliding inguinal hernias containing the urinary bladder.
• Bladder augmentation
• Foreign bodies in the bladder
• Medications (eg, viral protease inhibitors)
• Renal stone disease and gout

13. Predisposing Factors
• A diet deficient in animal protein,
• Poor hydration
• Recurrent diarrhea.

14. Predisposing Factors
• Males-
– Benign prostatic hyperplasia
– Urethral stricture
– Neurogenic bladder
– Diverticula
– Ureterocele
– Ladder neck contracture.
• Females-
– Incontinence repair that is too tight
– Cystoceles
– Bladder diverticula.

15. Pathology

16. Pathology
• The most common composed of uric acid.
• Less frequently
– calcium oxalate
– calcium phosphate
– ammonium urate
– Cysteine
– magnesium ammonium phosphate (when
associated with infection).
• In many cases, the core consists of one
chemical, and layers of different chemicals
form around this core.

17. Pathology
• In children-
– ammonium acid urate,
– calcium oxalate,
– mixture of ammonium acid urate and calcium
oxalate with calcium phosphate.
• In patients with spinal cord injuries,
composed of struvite or calcium phosphate.

18. Pathophysiology
•

19. Pathophysiology
• Bladder outlet obstruction>Stasis>crystal
nucleation and accretion>overt calculi.

20. Pathophysiology
• The factors that promote uric acid stone
formations are
1. Persistently low urinary ph
2. Dehydration leading to low urinary volume
3. High uric acid production.

21. Classification

22. Classification
• A primary bladder stone is one that
develops in sterile urine it often originates
in the kidney.
• A secondary stone occurs in the presence of
– infection
– outflow obstruction
– impaired bladder emptying
– foreign body.

23. Chemical composition

24. Chemical composition
• Most vesical calculi are mixed.
• Oxalate calculus
• Uric acid
• Cystine
• Triple phosphate

25. Clinical Features
•

26. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

27. Demography

28. Demography
• Incidence & Prevalence
• Geographical distribution.
• Age
• Sex
• Socioeconomic status
• Temporal behaviour

29. Demography
• Incidence & Prevalence-

30. Demography
• Incidence & Prevalence-
– 5% of urinary tract stones.

31. Demography
• Geographical distribution.

32. Demography
• Geographical distribution.
The incidence of bladder stones is
higher in developing countries.

33. Demography
• Age

34. Demography
• Age
– The age distribution has two peaks:
• 3 years
• 60 years.

35. Demography
• Sex

36. Demography
• Sex
– common in males, with male:female ratios
between 10:1 and 4:1

37. Demography
• Temporal behaviour

38. Demography
• Temporal behaviour
– Since the 19th century, the incidence of primary
bladder calculi in the United States and
Western Europe has been steadily and
significantly declining as a consequence of
improved diet, better nutrition, and infection
control.

39. Demography
• In regions where vesical lithiasis is endemic
in children, stone formation is more
common among
– boys younger than 11 years
– people from low socioeconomic backgrounds,
– is not usually associated with renal calculi
– less likely to recur after treatment (in
comparison with upper urinary tract calculi)

40. Symptoms

41. Symptoms
• Asymptomatic
• Suprapubic pain
• Dysuria
• Intermittency
• Frequency
• Hesitancy
•
• Nocturia
• Urinary retention.
• Priapism
• Enuresis.
• Terminal gross
hematuria and sudden
termination of voiding
with pain

42. Signs

43. Signs
• None
• Suprapubic tenderness
• Fullness
• Palpable distended bladder
• Cystoceles in women
• Stomal stenosis
• Neurologic deficits in patients with
neurogenic bladder.
• Van buren sounds.

44. Complications
•

45. Complications
• Squamous cell carcinoma of the bladder

46. Investigations

47. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology
– Germline Testing and Molecular Analysis
• Diagnostic Laparotomy.

48. Investigations
• Laboratory Studies
– Microscopic or gross hematuria
– Pyuria
– Bacteriuria
– Crystalluria
– Urine cultures positive for urea-splitting
organisms

49. Diagnostic Studies

50. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

51. Diagnostic Studies
Imaging Studies
• X-Ray- uric acid stones are radiolucent.
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

52. Diagnostic Studies

53. Diagnostic Studies

54. Cystogram

55. Differential Diagnosis

56. Differential Diagnosis
• Clot
• Fungal ball
• Papillary urothelial carcinoma

57. Management

58. Management
• Transurethral cystolitholapaxy
• Percutaneous suprapubic cystolitholapaxy
• Open suprapubic cystotomy
• ESWL

59. Management
• The energy sources
– mechanical device (ie, a lithoclast [pneumatic
jack hammer])
– ultrasonic device
– electrohydraulic device
– manual lithotrite
– laser.

60. Prevention

61. Prevention
• Eat less than hunger
• Drink water more than thurst.

62. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

64. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

66. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

69. Get my ppt collection
• https://www.slideshare.net/drpradeeppande/
edit_my_uploads
• https://www.dropbox.com/sh/x600md3cvj8
5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl
=0
• https://www.facebook.com/doctorpradeeppa
nde/?ref=pages_you_manage